A Patient with Abdominal Pain and Vomiting
A 39-year-old woman is admitted to you because of severe abdominal pain and
vomiting. She states that her illness began about 3 days ago with midepigastric pain
and nausea, and progressed to severe abdominal pain, nausea and vomiting. She
describes her pain as crampy, without any radiation, and continuous throughout the
day so that she cannot eat. She denies back pain, flank pain, diarrhea, dysuria,
hematuria, cough or any similar episode of pain before. She denies eating any unusual
foods, and her medications include NSAIDs for headaches, and oral contraceptives; she
recently took a course of metronidazole for Trichomonas vaginitis. She is employed as
a corporate vice-president, and lives with her daughter and husband. She does not
smoke cigarettes and drinks alcohol only on social occasions. Her parents both died of
cancer and she had a sister who committed suicide.
PE reveals a thin woman lying on her side in a fetal position. T 99, P 130, R 20,
BP 100/82. SKIN - warm, dry without lesions. LN - none. HEENT - normal with dry
mucosa. CHEST - clear. HEART - RRR 2/6 SEM; no rub or gallop. ABD - scaphoid
with diffuse tenderness to light palpation especially in midepigastrium; voluntary
guarding in all quadrants; no rebound; no organomegaly or palpable masses; BS absent.
PELVIC - normal with normal rectum. Stool trace heme positive. NEURO - nonfocal.
LABS
Na 142, K 3.1, Cl 100, HCO3 36, BUN 25 Cr 1.2, glu 60
Hb 13.3, Hct 39.7, WBC 14.8 (88 segs, 10 bands, 2 lymphs)
UA – normal; ABG (RA) 7.50/38/64
AST 102; ALT 75; Alk Phos 126; LDH 140 Amylase 806; Lipase 180
EKG – Sinus tach 130/flattened T waves in V2-V6
CXR - atelectasis at both bases; small left pleural effusion
1. What is the differential diagnosis of this patient’s abdominal pain? Which is most
likely?
2. What are the major causes of acute pancreatitis?
3. What is its presumed pathogenesis?
4. Are imaging studies helpful at this point?
5. The patient undergoes abdominal ultrasound which reveals no gallstones. How
would you manage this patient the day of admission?
6. Five days later the patient is febrile with continued abdominal pain and elevated
amylase. What would your concerns be, and what would you do?
7. The next day the patient has continued severe pain and fever despite your therapy,
and she develops dyspnea, and hypotension. The serum amylase increases to 1200,
platelet count drops to 60K and CXR reveals bilateral interstitial infiltrates. What
potential complications can account for her clinical course? Are there features at
presentation that could have predicted this subsequent clinical course?
8. Although the patient describes herself as only a “social drinker”, her husband
phones to tell you that he is concerned because she has been drinking several vodka
drinks each night and asks if her drinking is related to her illness. How do you
respond?